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Declaratio~ ot ~ Dornicile a~d Citizensh~p
TO THE STATE AND COUNTY TAX ASSESSOR, ~'33619
Sl. IUCIE COUNTY, FLORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that I am tiling this day in accordance and
in canformity with Chapter 222, Section 222.i7, Florida Statutes.
. C. ' / ~(,A.
1 was formerly a legal resident of -qr~-L~~
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(City) (State)
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and I resided at ~ ~ / - S ~ _ _ . However ! have changed my domiCile
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since ~s~-__ day of
u ~ _~:v- / ~ ~ > ~
- - 19
r
~ and 1 reside at ~ ~ ^
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLOItIDA
and this statement is to be taken as my declaration of citizenship, actuat legal residence a~d domicile in the State of Florida.
(Insert here any pertinent fads, such as sale of property or business, or relirequishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.) ~
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! ~ 33~19 !
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I FURTHER ~ERTIFY thnt 1 will comply witfi all other requirements of a(egal resident of this State.
I FURTHER CERTIFY fhat 1 have no intention to return to my former domi~ile, and I intend to remain in FORT
PIERCE, SAINT IUCIE COUNTY, FLORIDA, permanently.
. ~ ~
(Name)
~d ~~v . / ~ ~ S~ -
~
~ (Address)
~
Sworn to and subscribed before me this ~ day of /i/ , 19~~
~t~~:il{N:ft/~~~ .
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=,r~ ~ .;Z:I~~'i1~1,~~~0UR? Notary Public
- :i t ~ _
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8y ; % D.C. My Commission expires
.1 : 1 wt: ' -
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~~n dupliute and ori~inal fited with Cl~rlc Circuit Court, sod duplicat~ with Tax Assassor.)
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Efl~K~Q4 PACEtiBp. . . .
No 13 A
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